Provider Demographics
NPI:1699956961
Name:BRANCATO, JACLYN M (PA)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:M
Last Name:BRANCATO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:COLANTONIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:56 FRANKLIN ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1253
Mailing Address - Country:US
Mailing Address - Phone:203-709-8873
Mailing Address - Fax:203-709-8689
Practice Address - Street 1:56 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1253
Practice Address - Country:US
Practice Address - Phone:203-709-6004
Practice Address - Fax:203-709-3700
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001999363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970002629Medicare PIN